OMB No. 1820
- 0660 Expires :
**STA TE**  **AS SURA**  **NCES INDEPENDENT LIVING SERVICES FOR OLDER INDIVIDUA**  **LS WHO A RE BLIND**  **TITLE VII, CHA PTER 2 OF THE REHA**  **BILITA TION A** **CT OF 1973, A S A**  **MENDED** 1.

__________________________________________ ___________________ (Name of Agency) has been designated by the State as the sole State agency authorized to provide rehabilitation services to individuals who are blind, and, as the Designated State Agency (DSA) will solely authorized to adm inister the Independent Living Services for Older Individuals W ho are Blind (IL
- OIB) program under section 752(a)(2) of the Rehabilitation Act of 1973, as amended (Act). 2. Grant funds will be expended only for the purposes described in § 752(d) of the Act and 34 CFR 367.1. 3. The State will make available directly or through donations from public or private entities, non
- Federal contributions toward the costs of the program in an amount that is not less than $1 for each $9 of Federal funds provided in th e grant. ( § 752(f) of the Act and 34 CFR 367.11(b)). 4. The DSA will seek to incorporate into and describe in the State plan under section 704 of the Act any new methods and approaches relating to IL services for older individuals who are blin d that are developed by and determined to be effective from projects funded under the IL
- OIB program. ( § 752(h) of the Act and 34 CFR 367.11(c)) 5. At the end of each fiscal year, the DSA will prepare and submit to the Secretary a report, with respect to each project or program the DSA operates or administers under this part, whether directly or through a grant or contract, that contains, information that the Secretary determines necessary for the proper and efficient administration of this program, includ ing

— (1) The number and types of older individuals who are blind, including older individuals who are blind from minority backgrounds, and are receiving services; (2) The types of services provided and the number of older individuals who are blind and who are rece iving each type of service; (3) The sources and amounts of funding for the operation of each project or program; (4) The amounts and percentages of resources committed to each type of service provided;PAGE TWO
- IL
- OIB ASSURANCES (5) Data on actions taken to empl oy and advance in employment, qualified

— (i) Individuals with significant disabilities; (ii) Older individuals with significant disabilities who are blind; (iii) Individuals who are members of racial or ethnic minority groups; (iv) Wo men; and (v) Elderly individuals; (6) A comparis on, if appropriate, of prior year activities with the activities of the most recent year; and (7) Any new methods and approaches relating to IL services for older individuals who are blind that are developed by projects funded under this program. ( § 752(i)(2)( A) and 34 CFR 367.11(d)) 6. The DSA will provide services that contribute to the maintenance of, or the increased independence of, older individuals who are blind; and engage in: (1) capacity
- building activities, including collaboration with other agenci es and organizations; (2) activities to promote community awareness, involvement, and assistance; and (3) outreach efforts. ( § 752(i)(2)(B) and 34 CFR 367.11(e)(1)(2)) 7. The application is consistent with the State plan for providing IL services required by section 704 of the Act and subpart C of 34 CFR part 364. ( § 752(i)(2)(C) and 34 CFR 367.11(f)) 8. The DSA will meet each of the requirements set forth in Title VII, Chapter 2 of the Act and 34 CFR Part 367.
NAME OF APPLICANT
PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
SIGNATURE DATE

**Public Burden Statement** According to the Paperwork Reduction Act of 1995, no persons are required t o respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit ( Public Law 105
- 220
- 751 et seq

. )

. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., S W, W ashington, DC 20 202
- 4536 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820
- 0660. Note: Please do not return the completed Older Blind Application to this address.